Women with complex trauma: “it’s about building rapport”

There is a well-established relationship between substance use and complex trauma, which usually arises from traumatic events that occurred in childhood or over a long period of time. As Canadian addiction expert Dr Gabor Maté told the ABC: “early trauma is at the heart of pre-disposing people to being vulnerable to addiction”.

A woman accessing a Needle and Syringe Program is very likely to have experienced trauma such as sexual abuse, rape or domestic violence. Yet NSP workers have the biggest challenge on their hands, as theirs is the briefest intervention in the health sector.

Natalie Peach

Someone who can better explain the motivations of these women to keep using is Dr Natalie Peach. She’s the project coordinator on the COPE-A study at the National Drug and Alcohol Research Centre (NDARC). This study is trialling psychological therapies for co-occurring traumatic stress and substance use in adolescents.

“Often people self-medicate because of the post-traumatic symptoms that they’re experiencing, such as intrusive memories, hypervigilance and changes in mood,” Natalie says.

“The drugs can numb those symptoms but the person gets into a cycle where they can’t properly process the trauma.”

Not only can avoidance prolong the symptoms, but using substances can put the individual into a vicious cycle of being in dangerous situations and experiencing adult cumulative trauma.

And trauma has long-lasting effects. The longitudinal Adverse Childhood Experiences (ACE) study by the US Centers for Disease Control and Prevention began in 1995. This research found that the greater the number of childhood adversities experienced, the more susceptible an adult is to not only problematic substance use, high-risk sex, depression and suicidal ideation, but also to physical conditions such as obesity, increased inflammatory response, heart disease, cancer and lung disease.

The priority of an NSP is to offer health information and to be confidential and accessible, so clients often won’t be receptive to offers of treatment – either for trauma or substance use.

Mishma Kumar is Overdose Prevention Program Team Leader at Odyssey House. She says, “Usually when someone comes to an NSP they just want to leave with equipment.

“There are a whole lot of things happening in their heads that aren’t to do with them talking about their history,” Mishma says.

“They might be avoiding trying to think about their history, or they might even want to go use because they’ve been triggered. The last thing they may want to do is talk to an NSP worker, not even knowing if that person is a drug and alcohol clinician or a doctor.”

Talking to a client is opportunistic chess, says Dr Richard Cash. He’s a psychologist and trainer for Phoenix Australia – formerly the Australian Centre for Posttraumatic Mental Health – and provides policy support for services that want to act in a trauma-informed way.

“If I [as an NSP worker] had five minutes with someone, there would be a bunch of considerations around the time, the privacy, what they’ve actually asked to engage in, what the likelihood is that I’m going to have an ongoing relationship with this person,” Richard says.

“It’s important not to overstep the boundaries of your role. Someone might want to have a chat about what else the service can do and that might give me an opportunity for a very brief intervention or to provide support that might allow that person to engage more directly with another part of the service down the line.”

Mishma cautions that NSP workers risk coming across either as having a saviour complex or as judgmental if they push the idea of treatment too hard. “It’s about building rapport,” she says, which can range from casual conversation to advice to help reduce the harms of substance use.

There’s also the issue that an NSP might have intoxicated or aggressive people in the vicinity.

“What you wouldn’t do is ask a woman to open up, because that’s highly unsafe,” says Mishma. “Even if you can find a quiet space, if you open a can of worms it’s very hard to shove them back in.

“They might not want to touch the trauma for years, or they might want to touch it, but after detox.”

Mishma recommends acknowledging that the woman has various needs and that there might be organisations that can help. One might be the nearest Centre Against Sexual Assault (CASA).

“It’s about having that information on hand so you don’t have to go looking for brochures. You can say, ‘I can help you make the phone call if you want, if it’s too scary.’”

If a woman is being responsive to this approach, she might be interested in treatment. However the idea of being assessed can be intimidating to a client unwilling to immediately tackle her substance use, hence the importance of having confidential services such as CASA or a family-violence organisation on speed-dial.

In 2016, NDARC published its second edition of guidelines on managing mental health conditions among AOD clients, including how to informally assess for a history of trauma and PTSD.

Associate Professor Katherine Mills

“Although it may not be within an NSP worker’s capacity, knowledge of treatment options may be useful information to guide clients who are interested in seeking help,” says NDARC’s Associate Professor Katherine Mills, who is leading the COPE-A trial.

NDARC has also developed a booklet about trauma and substance use for clients themselves – handy if all the NSP worker has time to do is hand over some literature.

Women in abusive relationships

At Hair Expo in June 2018, the seminar ‘Safe Hands’ gave hairdressers tips on how to identify signs of family violence, the idea being that a salon might be one of the few places that a woman in a controlling relationship goes without her partner. According to Mishma, an NSP might be another.

“I think there is very much a space to have those conversations, but in a very delicate, non-judgmental way,” she suggests. “Not saying, ‘Have you thought about leaving?’ Because that is so close to the middle or end of the process.”

Mishma recommends asking the client if they would like the NSP worker to call a family violence organisation, emphasising that the service is confidential and that the woman can move at their own pace.

“It’s also about acknowledging that the relationship does give them something,” Mishma says. A violent partner may offer protection from others, for instance. “Or maybe they’re worried that another relationship could be worse and at least they know how to handle this one.”